Pilot study to evaluate the need and implementation of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care

Abstract Objectives To evaluate the need and feasibility of a nurse-led antimicrobial stewardship (AMS) programme in two Australian residential aged care homes (RACHs) to inform a stepped-wedged, cluster randomized controlled trial (SW-cRCT). Methods A mixed-methods pilot study of a nurse-led AMS programme was performed in two RACHs in Victoria, Australia (July–December 2019). The AMS programme comprised education, infection assessment and management guidelines, and documentation to support appropriate antimicrobial use in urinary, lower respiratory and skin/soft tissue infections. The programme was implemented over three phases: (i) pre-implementation education and integration (1 month); (ii) implementation of the intervention (3 months); and (iii) post-intervention evaluation (1 month). Baseline RACH and resident data and weekly infection and antimicrobial usage were collected and analysed descriptively to evaluate the need for AMS strategies. Feedback on intervention resources and implementation barriers were identified from semi-structured interviews, an online staff questionnaire and researcher field notes. Results Six key barriers to implementation of the intervention were identified and used to refine the intervention: aged care staffing and capacity; access to education; resistance to practice change; role of staff in AMS; leadership and ownership of the intervention at the RACH and organization level; and family expectations. A total of 61 antimicrobials were prescribed for 40 residents over the 3 month intervention. Overall, 48% of antibiotics did not meet minimum criteria for appropriate initiation (respiratory: 73%; urinary: 54%; skin/soft tissue: 0%). Conclusions Several barriers and opportunities to improve implementation of AMS in RACHs were identified. Findings were used to inform a revised intervention to be evaluated in a larger SW-cRCT.


Introduction
Antimicrobial resistance (AMR) is a significant global concern and increasing within residential aged care homes (RACHs). 1,2iven by high rates of antibiotic use (up to 80% of residents), 3,4 which is often inappropriate, 4 and the potential for AMR transmission across healthcare settings, 2,5 RACHs remain an important setting to target antimicrobial stewardship (AMS) initiatives.
Over 2018-19, 37% of Australian RACH residents were transferred to the emergency department and 31% admitted to a public hospital at least once, 6 increasing the risk of AMR transmission and placing both residents and hospitalized patients at risk of complex infections, longer hospital stays and mortality.
AMS within hospitals is well established, with demonstrable reductions in antibiotic use; 7 however, its impact and key components within RACHs remains uncertain. 7,8Interventions are frequently multifaceted and multidisciplinary, incorporating education, guidelines, and audit and feedback. 91][12] RACHs are complex settings and present several challenges for successful implementation of AMS, including staffing mix, workload, organizational structure, onsite availability of physicians and pharmacists, and increasingly complex residents with multimorbidity and cognitive impairment. 13ecent randomized controlled trials (RCTs) have sought to investigate the impact of AMS on antibiotic use and AMR in RACHs; 14,15 however, few have explored the barriers and facilitators of implementing AMS, 16 particularly in Australian RACHs. 17,18his study aimed to evaluate the need and feasibility of a nurse-led AMS intervention programme in two Australian RACHs to inform a larger stepped-wedge, cluster RCT (SW-cRCT). 15

Study design and setting
A mixed-methods pilot study was performed in two RACHs in regional and metropolitan Victoria, Australia.Both RACHs provided 24 h nursing care with GP support.The study was performed over three phases between July 2019 and December 2019: (i) pre-implementation (1 month education and intervention integration); (ii) implementation (3 months); and (iii) post-intervention feedback (1 month).This included the collection of resident, facility, infection and antimicrobial use data over the three phases to support the needs assessment for AMS interventions in RACHs.

Intervention
Full intervention procedures are detailed in the published protocol. 15In brief, the nurse-led AMS intervention comprised education, RACH-specific guidelines, documentation forms and fact sheets to support appropriate antimicrobial prescribing for urinary tract infections (UTIs), lower respiratory tract infections (LRTIs) and skin and soft tissue infections (SSTIs).Education included face-to-face education, an online interactive workbook with equivalent information, and fact sheets targeting improved diagnosis and antimicrobial management of common infections.This aligned with the specific intervention procedures to commence during the intervention phase.RACH staff, GPs and pharmacists had access to all resources.Both RACHs had no pre-existing AMS programme in place prior to the study.
Education was provided by the study coordinator (research pharmacist) to RACH staff, including registered nurses (RNs), enrolled nurses (ENs), personal care attendants (PCAs) and clinical managers.Education completion was strongly encouraged for all relevant staff in either mode (face-to-face or self-directed via written/online material).Residents and families received monthly face-to-face education and a fact sheet.
RACH-specific guidelines were developed to support the initial assessment and antimicrobial management of UTIs, LRTIs and SSTIs, adapted from existing antibiotic initiation criteria, 19 infection surveillance 20 and prescribing guidelines. 21Assessment guidelines included minimum signs and symptoms of infection for antibiotic initiation, investigations and considerations for hospitalization.During the intervention period, RACH staff were advised to refer to the guidelines if they suspected a resident had signs or symptoms of infection prior to referral to the GP.Other resources including the management guidelines and resident fact sheets were intended to be used by all RACH staff, GPs and pharmacists, as required along the infection assessment and management pathway.

Implementation
To support implementation, the nursing leadership team [clinical manager(s), general manager] were consulted prior and during the intervention to tailor implementation.The leadership team selected a 'nurse champion' responsible for education completion, distribution and placement of resources onsite, and staff compliance with intervention procedures.Both RACHs selected a clinical manager, an RN by background, to provide study leadership onsite.Up to four face-to-face 1 h and twiceweekly 15 min education sessions at nursing handover meetings were provided at each RACH.Clinical managers prioritized the attendance of regularly rostered RNs/ENs for 1 h education as they were perceived to have the greatest input in intervention procedures (attendance of total employed including casual workforce: 30% RNs/ENs, 30%-35% PCAs).

Data collection
Baseline RACH, staff and resident data included occupancy, staffing mix and resident characteristics.All systemic antimicrobial use, infections and hospitalizations were collected from paper-based residents' medical records.These data were collected to provide insight into baseline infection and antimicrobial rates as the short intervention period was insufficient to evaluate intervention effectiveness.
Post-intervention qualitative feedback included one-on-one semistructured interviews and an online staff questionnaire covering an understanding of antibiotic appropriateness and resistance, and usability and usefulness of intervention resources.The questionnaire (available as Supplementary data at JAC-AMR Online) primarily comprised questions on the Likert scale (strongly disagree to strongly agree) and additional open-ended questions to obtain feedback on each of the intervention resources.Interviews were audio-recorded and performed by two qualitative researchers (E.W. and T.T.).Researcher field notes documented observations related to intervention delivery.

Analysis
Transcribed interviews and field notes were coded and thematically analysed independently by two researchers (N.J. and L.T.) using inductive and deductive approaches to identify implementation barriers (NVivo, v20.3).Questionnaire data were summarized descriptively and considered alongside the initial themes to develop the final list of themes.Resident and antimicrobial data were summarized descriptively (Stata, v17.0).

Ethics
Ethical approval was obtained from the Alfred Hospital Human Research Ethics Committee (HREC) (HREC/18/Alfred/591). Consent to obtain data from residents' medication records was waived.Written informed consent was obtained for interviews.Consent was implied on completion of the online questionnaire.A total of 135 residents were enrolled (Table 1).Residents were primarily female (71%), median 90 (IQR: 83-93) years of age, diagnosed with dementia (60%), required full assistance with activities of daily living (70%), and resided in their RACH for a median 31 (IQR: 10-59) months.

Implementation
Post-intervention feedback was obtained from seven one-on-one interviews (two clinical managers, three RNs, one general manager, one resident) and online questionnaire (n = 22).The questionnaire was completed by four RNs, two ENs, 13 PCAs, two clinical managers and one GP.
Of the questionnaire respondents, over 85% reported the resources were moderately to extremely useful in supporting improved antibiotic use and at least 77% were moderately to extremely likely to use them again.Improvements focused on simplifying education for PCAs and reducing content within guidelines and forms.
Six key themes related to implementation barriers identified from researcher field notes, interviews and the questionnaire included: aged care staffing and capacity; education completion; resistance to practice change; staff roles in AMS; leadership and intervention ownership at the RACH and organization level; and family expectations (Table 2).Key improvements included strategies to increase education accessibility and completion (online, mandatory completion, staff renumeration), guideline integration into standard operating procedures, and increased engagement and capacity building of RACH and organization-level leadership targeting uptake, compliance and intervention ownership.

Discussion
This study evaluated the need and feasibility of implementing a nurse-led AMS programme across two RACHs to inform a multifaceted AMS intervention for an SW-cRCT.Half of all antibiotics for UTIs, LRTIs and SSTIs did not meet minimum criteria for initiation, supporting the need for strategies to improve appropriate antimicrobial use.Overall, the AMS programme was well received; however, several opportunities to improve implementation were identified.Implementation themes included staff perceptions of their role within AMS, and workforce and workload challenges, 17,18,22 highlighting the complexities of implementing quality improvement programmes within RACHs.
Up to almost a quarter of residents were prescribed an antimicrobial on any given month, with a high level of variability between 2% and 21%.This prevalence is higher than the prevalence reported from the 2019 Australian Aged care National Antimicrobial Prescribing Survey of 568 Australian RACHs, which found that 5.5% of residents were prescribed at least one systemic antimicrobial, 23 and higher than that found in 3052 RACHs across 24 European countries between 2016 and 2017, with a mean prevalence of 5.8%. 24Our findings are, however, lower than a review of prescription data of 3459 Australian RACH residents between 2016 and 2019, which identified a mean 18.9% of residents received an antibiotic monthly. 25hese differences in estimates may be due to the variability in data collection time periods (point and period prevalence) and potential seasonal variability in antimicrobial prescribing.Approximately half of antibiotics prescribed in this pilot did not meet minimum criteria, comparable to previous Australian audits, 26 highlighting the need for ongoing AMS strategies to improve their appropriate use in UTIs, LRTIs and SSTIs.
Opportunities to improve implementation targeted education uptake and perceptions of RACH staff roles within AMS.PCAs comprise 70% of the Australian RACH workforce 27 and are often the first to identify symptoms and provide information to residents and families.Despite this, clinical managers and RNs did not perceive a significant role for PCAs within AMS, citing key knowledge gaps, conflicting with PCAs' self-perceived role and interest in improving their knowledge.This is consistent with previous Australian RACH staff interviews, identifying exclusion of PCAs from AMS education despite interest to improve antimicrobial use. 18Aged care staff did not perceive that their role extended to influencing prescribing decisions, expressing it was the GP's role and a lack of confidence in challenging decisionmaking, consistent with previous Australian aged care surveys. 28ursing staff have previously been identified as having a key role in the multidisciplinary AMS team to support reductions in antimicrobial use and improve clinical outcomes, [10][11][12] and highlighting the importance of addressing barriers to successful implementation.Addressing these knowledge and confidence gaps requires inclusive education and strategies to support attendance including flexible modes, dedicated time and remuneration for completion, and consideration of staff turnover to ensure new and temporary staff are also provided with education opportunities.
Workforce and workflow challenges are consistent barriers to implementation of quality improvement programmes. 18,22Staff turnover, insufficient number of RNs and reliance on agency staff were identified as key barriers in this pilot and internationally. 18ged care staff were uncertain how to prioritize new AMS procedures in the setting of competing pressures and organizational changes.Tailoring AMS workflow under the constraints of existing workforce challenges and prioritizing AMS in RACHs is necessary to drive acceptance and adherence.
This study had several strengths and limitations.The intervention was championed at each RACH by existing clinical managers to support implementation.Regional and metropolitan sites provided broader representation of implementation barriers.Ongoing feedback during the intervention was provided informally by staff and contributed to revisions that informed the final intervention and implementation plan for an SW-cRCT.High staff turnover and poor availability of staff (particularly PCAs) at the time of evaluation limited our sample size.The short intervention period did not allow for the intervention to be evaluated for effectiveness; however, the refined intervention will be evaluated in an SW-cRCT.The absence of a pharmacist or dedicated staff member to provide AMS education may limit generalizability and supports the need to expand modes of education delivery to improve accessibility and translation beyond this pilot.Although both RACHs were managed by the same provider, variability in culture, workforce and procedures may limit generalizability to other RACHs more broadly.

Conclusions
This pilot identified a need for AMS strategies to improve the appropriateness of antibiotic use and several barriers and opportunities to improve its implementation in RACHs.Tailored strategies Jokanovic et al.Antimicrobial stewardship in residential aged care

Table 1 .
Resident baseline characteristics

Table 2 .
Barriers to implementation of antimicrobial stewardship and illustrative quotes from aged care staff a interviews (n = 6), questionnaire (n = 22) and researcher field notes

Table 2 .
Continued required to improve education uptake and capacity of nursing staff to lead AMS programmes in the context of workforce and workflow challenges in RACHs.Findings were used to inform a revised intervention to be evaluated in an SW-cRCT across 12 RACHs.Pressure to prescribe antimicrobials from family members in the absence of appropriate indications for use.'Sometimes it's hard because we have family members that are insistent on their Mum or Dad having antibiotics, even though there is not really any clinical indication that they need it, like maybe the full ward test was clear or they were asymptomatic, but they are still quite insistent because they believe that Mum's coming down with a UTI or chest infection, so we have to advocate, just give them the information they need and get the GP on board as well.'-GeneralManager ADL, activity of daily living.
are a Aged care staff: RNs and ENs, PCAs and clinical manager.